65 year old male with shortness of breath

THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT        

CHEIF COMPLAINTS:

A 65 year old male resident of choutuppal farmer by occupation came to OPD with chief complaints of 

SHORTNESS OF BREATH AND PAIN ABDOMEN

Since 2 days.

HOPI:

Patient was apparently asymptomatic 25 years back years back then he developed cough with thick blood stained sputum and went to a private hospital for checkup and was diagnosed with TB and was on ATT for 6 months and then the symptoms of cough subsided.

2 years back he had Shortness of breath  (Grade 2) type which is insidious in onset and went to local RMP and was relieved temporarily on medication ( drug - unknown) from then he had intermittent shortness of breath which relieved on the medication temporarily. 

6 months back he met with Road traffic accident and suffered an injury to left tibia and left rib

 He was taken to nearby hospital and was put on pop cast for 40 days and used calcium tablets.

5 days back there was Pain in umbilical region which was insidious in onset and diffuse.

He also developed SOB of grade 3 type which was insidious in onset and temporarily relieved on medication.

Patient had constipation since 3days but 

Yesterday he had 10 episodes of loose stools 

There is history of productive cough with thick sputum 

fatigue; sweating- present 

No history of palpitations

NO H/O fever

NO H/O vomiting 

NO H/O orthopnea, palpitations

NO H/O loss of weight

 ROUTINE:

The patient used to be a farmer but stopped working 6 years back due to weakness and was mostly confined to his home and surroundings and sits ideally.

PAST HISTORY:

History of TB 25 years back

Known case of SOB since 2 years

No history of HTN, DM, CAD, Asthma and thyroid abnormalities,epilepsy

PERSONAL HISTORY:

Diet: mixed

Appetite: decreased 

Sleep: inadequate due to SOB

Bowel : irregular 

Bladder:burning micturition present

Addictions-used to drink alcohol and toddy occasionally -stopped 20 years back

No history of smoking

FAMILY HISTORY:

Not significant.

GENERAL EXAMINATION: 

Patient was conscious, cooperative,well oriented to time,place , person. Moderately built and moderately nourished

pallor was present

no cyanosis

no icterus

no clubbing

no generalised lymphadenopathy

no pedal edema

VITALS::

TEMP AFEBRILE

BP 110/70 mmhg

Pulse Rate  78 bpm rhythm(regular)character(normal )

Respiratory Rate :21CPM Abdomino thoracic type

Spo2- ?

SYSTEMIC EXAMINATION:

Abdomen: Soft and non tender. Bowel sounds heard . Skin over abdomen smooth 

Shape - scaphoid

Tenderness - no

Free fluid - no

Liver - not palpable

Spleen- not palpable

Cardiovascular system:   

INSPECTION:-

Chest appears normal in shape

Apex beat is not visible

PALPITATION:

Apex Beat - diffuse No palpable murmurs (thrills)

ASCULTATION:-

S 1; S 2 heard

Central nervous system: No focal neurological deficits.

Respiratory system: 

INSPECTION:

 Shape of Chest - normal

 Trachea position central

 Movements of the chest: Respiratory rate:- 21cpm Type- abdomino thoracic type no accessory muscles involved.

PALPITATION:

 No local rise in Temperature and tenderness

 Expansion of the chest- equal in all planes 

PERCUSSION:

Resonant all over the chest except infraxillary area left side

AUSCULTATION:

Normal breath sounds were heard in all areas except the left infra axillary where there are decreased breath sounds.

INVESTIGATIONS:

29/11/22

30/11/22

01/12/22

PROVISIONAL DIAGNOSIS:

Pain in the abdomen under evaluation

Heart failure?? with reduced ejection fraction (52%)w

With Anemia under evaluation with Chronic kidney disease

with a history of Pulmonary TB- 20 years back

TREATMENT: 

Head end deviation up to 30 degree

supplementation if spo2<90%

MONITOR 4- hrly

NEB - SALBUTAMOL 4 hrly

FEVER CHART 4 th hrly 

InJ LASIX 4O mg